Uterine Cancer: Early evaluation and detection increases survival rate

Uterine cancer is cancer that starts in the cells of the uterus, also known as the womb. In the United States, uterine cancer is the most common gynecologic cancer and the fourth most common cancer in women. In 2020, over 65,000 new cases will be diagnosed and over 12,000 women will die from uterine cancer. Approximately 3% of women will develop uterine cancer. Unlike other cancers, the incidence of uterine cancer continues to increase. This increase is mostly due to the link between obesity and most uterine cancers.

What is uterine cancer?

The uterus is connected to the vagina by the cervix (the strong fibrous lower portion of the uterus). In pregnancy, the uterus is where a fetus grows. The uterus has two layers. The thin lining of the uterus is called the endometrium and the surrounding thick muscular wall is called the myometrium. In women who are pre-menopausal, or still having regular monthly periods, the endometrium thickens every month in the event of pregnancy. If no pregnancy occurs then the lining will shed as a monthly menstrual cycle. After menopause, the lining of the endometrium becomes inactive and thins. The vast majority, or approximately 90%, of uterine cancers, begin in the endometrial lining of the uterus and are referred to as uterine adenocarcinomas. Cancers of the smooth uterine muscles are largely classified as sarcomas but are much rarer than uterine adenocarcinomas.

What are the symptoms of uterine cancer?

The most common symptom of uterine cancer is abnormal vaginal bleeding. In pre-menopausal women, abnormal vaginal bleeding is defined as heavy irregular or unpredictable cycles and bleeding in between cycles. In menopausal females, any bleeding after menopause is abnormal, even small amounts of spotting, and should be evaluated promptly.

Other symptoms of uterine cancer can include:

• Pelvic pain
• Pelvic bloating
• Abnormal vaginal discharge

The CDC offers a gynecologic cancer symptoms diary that can be used to track any symptoms to decide when you need to see your doctor which can be found here.

What are risk factors for uterine cancer?

Uterine cancers can develop due to a mix of environmental factors, genetic factors, and sometimes without any identifiable cause.

General factors associated with endometrial cancer include:

• Age: The average age of endometrial cancer diagnosis is in the early 60s and most will be older than 50 years.
• Race: Uterine cancer is increasing at a higher rate in black women increased and black women are more likely to die from uterine cancer than white women. This can be attributed to healthcare disparities and associated with later diagnosis at higher stages in black women.

The most common environmental factors associated with endometrial cancer include:

• Obesity: Fatty tissue produces excessive estrogen hormone which can cause irregular growth of the endometrium that leads to cancer. About 70% of endometrial cancer is linked to obesity. Diabetes and diets high in animal fats are linked to increased endometrial cancer risk.
• Increased estrogen exposure: This includes the use of estrogen replacement, those without a history of pregnancy, or women who start periods at a young age or menopause at an older age.
• Tamoxifen: Tamoxifen is a drug used to prevent breast cancer in those at increased risk. While tamoxifen is associated with a small increased risk of endometrial cancer, the benefits generally outweigh the risk and the medication is given under the close supervision of specialized cancer doctors.
• Radiation: Women with a history of radiation in the pelvic area are at increased risk of developing future uterine cancers, including sarcomas.

Uterine cancers can run in families with certain genetic conditions. Uterine cancers can be increased in families with genetic risk for colon cancer. Lynch syndrome or hereditary non-polyposis colon cancer (HNPCC) is the most common of these conditions. Lynch syndrome will be found in up to 5% of women with endometrial cancer, especially those diagnosed at a younger age. Tumor testing is recommended for all women with endometrial cancer to determine who should be tested for Lynch Syndrome.

Is there a screening test for uterine cancer?

While there is no routine screening test for all women without symptoms or a known genetic risk. However, any women experiencing the symptoms of endometrial cancer, especially post-menopausal bleeding, should be promptly tested for endometrial cancer.

How is endometrial cancer diagnosed?

Your doctor should evaluate your symptoms with a pelvic exam and biopsy and possible imaging studies. A sampling of the lining of the endometrium can be done with either an in-office endometrial biopsy or in the operating room using by hysteroscopy (camera designed to evaluate the endometrial cavity) combined with a dilation and curettage (D&C). Your doctor may also recommend an ultrasound of the pelvis or a computed tomography (CAT or CT) scan.

How is uterine cancer treated?

If uterine cancer is diagnosed on biopsy or D&C then you will be referred to a specialist trained in treating endometrial cancer, called a gynecologic oncologist. Most endometrial is initially treated with surgery to remove the uterus, called a hysterectomy. A gynecologic oncologic surgeon may also recommend removal of pelvic and/or abdominal lymph nodes at the same time as the hysterectomy. Lymph nodes are tissue organs that filter the blood and are often the first place of cancer spread in endometrial cancer. A majority, or nearly 60%, of endometrial cancers, are found in an early stage and confined to the uterus alone. If endometrial cancer is found to be at a higher risk or has spread to other organs, then radiation or chemotherapy will be recommended by your gynecologic oncologist. For uterine endometrial cancer, the 5-year survival rate, or the percentage of women alive 5 years after diagnosis is greater than 80%. Thus, early evaluation and detection is the best strategy to prevent uterine cancer deaths.

What can I do to prevent uterine cancer?

Prompt and thorough evaluation of any abnormal vaginal bleeding, especially in the setting of menopause is especially important in preventing or early detection of uterine cancer. This is especially important for older and black women. Maintaining a healthy diet, a healthy weight, and careful management of diabetes can all decrease endometrial cancer risk. For those with a uterus and on hormone replacement therapy, the use of a progestin combined with estrogen can prevent endometrial overgrowth and cancer risk. Those women on long-term combined oral contraception pills or progesterone intrauterine devices (IUD) are at lower risk of endometrial cancer. For those with a strong family history of endometrial or colon cancer, talk with your doctor to see if genetic testing is right for you. Those with Lynch Syndrome or other genetic conditions should undergo increased cancer-specific screenings.

Dr. Tara Castellano is a Gynecologic Oncologist with the LSU Health Sciences Center Department of Obstetrics and Gynecology. She is originally from the New Orleans area and completed her medical degree at LSUHSC in New Orleans where she first fell in love with the subspecialty of gynecologic oncology. Dr. Castellano completed her Obstetrics and Gynecology residency at the University of North Carolina in Chapel Hill, NC. After completion of residency, Dr. Castellano completed a fellowship in Gynecologic Oncology at the Stephenson Cancer Center at the University of Oklahoma, in Oklahoma City. As a Gynecologic Oncology fellow. During the fellowship, she received specialized training in complex surgery, chemotherapy, and novel therapies to treat gynecologic cancers.

Dr. Castellano is board-eligible in both Obstetrics and Gynecology and in Gynecology Oncology. She is an active member of the Society of Gynecologic Oncology and recently served on the 2020 Annual Program Committee. Dr. Castellano’s research interest includes clinical trial design, quality initiative models, identification and elimination of health disparities, and improvements in cancer care delivery. She has published and nationally presented dozens of scientific abstracts and articles over the past several years and is actively engaged in research. Dr. Castellano is thrilled to return home and is excited to improve care and treatment options as well as expand clinical trial access to women with gynecologic cancers in south Louisiana.